Theoretical discussion of disease conditionGastric ulcers are generally caused by a variety of environmental factors, most of which are contributedby “hostile” factors such as NSAID use, alcohol abuse, and tobacco use, among many others. Smokingas well as age can increase a person’s risk of developing a perforated gastric ulcer. These factorsincrease the risk because they affect the gastric secretion in the gastric mucosa. Recurrence of aperforation is high in populations over 60 years of age. Additionally, mortality rate due to perforatedgastric ulcers is also increased in these populations. [3]Alcohol abuse is also strongly correlated with recurrent gastric bleeds from a perforated gastric ulcer.According to a study, alcohol abuse was identified in “19.7 % of patients with non-variceal uppergastrointestinal bleeding.” Recurrent bleeds were as high as 16.7% in alcohol abusers versus 9.1% inthose that did not abuse alcohol. Patients with non-variceal upper gastrointestinal bleeding that alsoabuse alcohol are at a higher risk of re-bleeding and their risk of mortality is increased. Most patients arefollowed by a primary care doctor or gastroenterologist and placed on a long-term proton pump inhibitor toprevent further peptic ulcers and gastric bleeds. [4] It is also strongly recommended that patients limitNSAID use, alcohol, and smoking during treatment of Peptic Ulcer Disease.

Usual treatment of Peptic Ulcer Disease and perforated peptic ulcers.If a patient is found to have gastro-intestinal bleeding or discomfort, either a stool sample is tested or anexploratory endoscopy is performed. The endoscopy is a more invasive method where samples orbiopsies of the ulceration may be taken to determine the cause is H.pylori. Once the bacteria is found tobe the culprit of the ulcer, antibiotics are administered to eradicate H.pylori from the patient’s digestivetract. If the ulcer is bleeding, cauterizing and closing the perforation safely is the most immediate concern.While there are several causes of peptic ulcer disease, oftentimes a person’s risk factors can easily bedecreased by making several lifestyle changes early on in life. Quitting smoking or reducing NSAID andalcohol consumption are some of the most profound ways to prevent an H.pylori infection. Smoking inparticular has been found to adversely affect the gastric mucosal protective mechanisms, thuspredisposing a person to peptic ulcer disease. Several clinical studies have observed that smokers aremove likely to develop ulcers which subsequently are more difficult to heal if smoking cessation does notoccur.Other than reducing alcohol consumption, NSAID use or smoking cessation, some patients may beplaced on a proton pump inhibitor or antibiotics. A proton pump inhibitor may be given to a patient toprevent additional ulcers as well as to prevent an existing ulcer from bleeding again. It works by reducingthe amount of stomach acid produced while the ulcer heals. [5]Diagnosing whether or not a patient has a peptic ulcer can be determined through various differentdiagnostic tools. Some research suggests that gastric ulcers can be found by using a CT scan. Otherdiagnoses are found via exploratory endoscopy. The perforation is usually repaired laparoscopically bycauterizing the crater. Duodenorrhaphy or gastrorrhaphy, suturing of either a duodenal ulcer or gastriculcer, has long since replaced the need for gastric resection which used to be a common treatment inreparation of a perforated peptic ulcer. [6] Due to the seriousness of this illness it is important that thediagnosis is definitively made and repaired in a timely manner.

Patient’s symptoms upon admission leading to present diagnosisSome symptoms associated with peptic ulcer disease, or a perforated gastric ulcer can include, but arenot limited to bloody or dark tarry stools, fatigue, vomiting, and weight loss. All of these classic symptomswere presented in the patient at the time of his visit. FK was admitted with severe malaise and fatiguewith fainting spells at his home. He was found confused and was previously referred to Fort HamiltonHospital from the patient’s ENT at UC West Chester. The patient was severely underweight and wasexperiencing some slight abdominal discomfort. Most of his perforated ulcer symptoms were hidden bythe fact that he was not eating well due to his mandibular fracture (and possible jaw mass) as well the

mass on the base of his tongue. Additionally, the patient’s history of alcohol abuse also covered up someof the symptoms he was experiencing such as the weight loss and loss of appetite.Following the exploratory endoscopy, FK was found to have a severe gastric bleed. Cultures were takenof the patient’s stool as well as inside the stomach lining, showing that he did have an H.pylori infection.The etiology of peptic ulcer disease shows overwhelming evidence blaming smoking as highly correlatingwith the disease, as explained throughout this case study. In smokers under the age of 75, H.pyloriinfection was found to account for about 77% of all gastric perforations. Excessive NSAID use alsoaccounted for nearly one third of gastric perforations from H.pylori infections. [6]There are some indications that radiation treatment or exposure to radiation treatment can predispose apatient to be more susceptible to gastric ulcers. This is usually due to the disruption of fast growing cellssuch as the gastric lining and gastric mucosal secretions. FK had approximately 42 radiation treatments inthe past due to tongue cancer. The treatment would have been focused on his neck and upper GI area.Unfortunately there are not enough studies to show if radiation has lasting effects to possibly indicate it inbeing part of the etiology of peptic ulcer disease.

Treatment: Medical (mention any diagnosis tests and state the results obtained.)Surgical procedures and findings and resultsDuring FK’s first admission, an exploratory colonoscopy as well as an exploratory endoscopy wereperformed. During the colonoscopy, the physician found that the patient’s colon was filled with pus froman infection. Blood was also found in the patient’s stool, indicating that there was an upper GI bleed.Once the endoscopy was performed, No esophageal varices were found which often occur in those withliver disease and those with a history of alcohol abuse. Prior to the endoscopy, esophageal varices werethought to be a possible cause of the bleed. However, the physician did find a bleeding perforation in thepatient’s stomach which was immediately repaired through cauterization. To prevent recurrent bleeding,FK was placed on a proton pump inhibitor. Proton pump inhibitors work by reducing the acid in thestomach, therefore allowing a clot to form and stabilize where the perforation was. Proton pump inhibitorsare often used to prevent recurrent bleeds when used in corroboration with antibiotics. Though, thistreatment is most effective if a patient is not taking NSAIDs. In fact, it is strongly recommended thatpatients completely discontinue the use of NSAIDs during Peptic Ulcer treatment. However, the only trueway to prevent a recurrent bleed is to completely eradicate H.pylori. [8]FK was observed after his initial gastric repair and unfortunately, his stool continued to look black andtarry, indicating that his bleed was still ongoing. An additional repair was made via cauterization and hisproton pump inhibitor dose was increased. Unfortunately, there is not enough research that showswhether a high dose orally or intravenously is more effective than a lower dose orally or intravenously. [9]Shortly after FK’s second repair he was admitted to an extended care facility where they could watch hisimprovement closely.Two days after FK was admitted to the extended care facility, he was admitted again with a bleeding ulcer.The physician indicated that the patient had failed proton pump inhibitors and required additional surgery.A vagotomy and antrectomy were considered, but due to the patient’s surgical risk being increased due tohis cirrhosis and high blood pressure these procedures were declined. A vagotomy is a surgical operationwhere one or more portions of the vans nerve are cut, decreasing a patient’s gastric secretions. This canbe performed in conjunction with an antrectomy, or removal of the distal third of the stomach. Theseprocedures, particularly a vagotomy can be used in the management of severe peptic ulcer disease,however with they predate pharmacological use of proton pump inhibitors. A vagotomy sometimes isindicated if a patient is resistant to proton pump inhibitors such as in FK’s case.[10]The surgical team decided that his ulcer was to be repaired once again by placing hemoclips on bothsides of his ulcer to stop the bleeding. Though during surgery, the ulcer was found to be reduced in sizeand was apparently healing, a vessel was still exposed and required attention. FK was observed forimprovement over another week-long admission after his third surgery. A follow up endoscopy was

scheduled as an outpatient procedure after his discharge to ensure that his gastric perforation washealing properly. The results of the patient’s follow up endoscopy have yet to be recorded in his chart.

Medical Nutrition Therapy:FK lives alone and normally purchases and prepares for himself with some assistance from familymembers. He often uses a crockpot for cooking soft foods and though he has been told by severalphysicians to follow a low sodium diet, he does not follow one at home. FK eats all of his meals at homeand only eats about 2 meals a day. FK has trouble chewing and swallowing due to his broken jaw andmass on his tongue, so the texture of his food is important. He denied choking on any particular texture offood but claimed that it was easier to chew and swallow when food was soft and had extra gravy orsauce.FK’s diet in the hospital ranged from Soft Dysphagia to Heart Healthy. Tube feed was discussed with theGastroenterologist and Nurse Practitioner but was not recommended due to the patient’s recurrent gastricbleeding. It was also recommended that a Speech Therapist do a swallowing evaluation with the patient,however the patient was uncooperative during each attempt made. Speech Therapy was unable toperform any substantial swallow evaluation so he was placed on a Soft Dysphagia diet per his reportedhome diet. Sodium restriction was not an important concern during his visit due to a noted loss of musclemass and subcutaneous fat.During the patient’s visit Boost Plus was also sent as supplements during each meal to increase hiscalorie intake. FK did not drink any boost at home but drank several Boosts during his admission at thehospital. In fact, according to nursing staff at Fort Hamilton, the Boost Plus drinks were almost the onlyitem on his tray that he consistently consumed. Though FK did not consume much, other than the BoostPlus, he did end up gaining some weight by the end of his second visit.According to ASPEN guidelines a nutrition screen is to be performed within 24 hours of a patient’sadmission to an acute care setting. FK was referred to nutrition care for assessment with unplannedweight loss, poor oral intake, and difficulty chewing and swallowing. During the patient’s assessment, itwas noted that he lost approximately 15.5% of his body weight in about one month’s time. His intake wasalso severely decreased to less than 50% of his usual intake for about a month or more since he startedhaving pain in his jaw. This two issues immediately indicated that a physical malnutrition screening wasnecessary. [11]Upon, his physical assessment, FK was found to have severe malnutrition with significant loss of musclemass and subcutaneous fat. Due to his protein-calorie malnutrition, his needs were significantly higherthan the average person. As mentioned previously, tube feed was discussed with patient’sgastroenterologist but was declined due to FK’s recurring gastric bleeds. Therefore, Boost Plussupplements were given three times a day to increase protein and calories.

According to his 24 hour recall at home, FK is severely lacking in calories and protein as well as severalvitamins and mineral. The patient also drinks more than the recommended amount of alcohol per daywhich may also contribute to malabsorption of key vitamins and minerals. According to several studies, aprimary issue with patients that abuse alcohol is megaloblastic anemia. This particular type of anemia isassociated with a deficiency in folate. [12] FK is currently on a vitamin regimen that includes folate.However, according to the patient’s labs he is still found to be anemic. This could be due to his GI bloodloss as well as his possible alcohol induced folate deficiency. FK would benefit from supplementation ofboth folate and iron.Some nutrition interventions for FK included promoting protein intake, promoting oral intake, and nutritionsupplementation with Boost Plus. The patient seemed receptive to increasing his protein and oral intakeand was willing to drink Boost Plus. However, during each subsequent visit he became increasingly

irritable and unwilling to cooperate. During his second visit, FK refused a physical malnutrition screen andhis body language suggested that he was disinterested in any information or assistance given.FK was discharged to an extended care facility who would subsequently take care of all of his nutritionalneeds. Physical Therapy and Speech Therapy found that the patient was unable to take care of himselfand required assistance. The patient’s daughter assisted him when she was able to at home, howeverduring his admission she did agree that it was best for FK to be admitted to a facility that would give him“around the clock” care. The patient would be followed by physicians and dietitians at the facility forimprovement. He also had a scheduled follow-up endoscopy planned for a week or so after his discharge.